Information

VOHS. 011.1 Vemco Group Accident and Incident Investigation Report Form

  • Report Date and Time

  • Person Completing Report

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Part A

Incident Details

  • Business Unit

  • Enter Name of Business Unit

  • Location of Incident Enter the location of the incident or select from map.
  • Date of Incident

  • Description of incident.

  • Photos of incident Provide a photo if possible.

  • Were there witnesses to the incident?

  • Witness Details

  • Witnesses
  • Witness Name

  • Witness Phone No if available

  • Witness Address if available
  • Recommendations (Reoccurrence Prevention) What Actions / Precautions could be taken to prevent this incident from re- occurring?

  • Type of report

  • List Persons Involved

  • Person(s) Involved
  • Name

  • Relationship to Vemco

  • Please enter the name and contact details of the contractor.

  • Please provide name and contact details of other party.

  • Mechanism of Injury

  • Describe Mechanism of injury

  • Body Location

  • Describe Body Location(s)

  • What was the person doing at the time of the incident

  • Describe what the person was doing.

  • Nature of Injury

  • Describe the nature of the injury.

  • Select Environmental Impact

  • Did the incident involve a spill?

  • Select spill type.

  • Which one of the following was the ENVIRONMENTAL incident caused by?

  • Description of cause.

  • What Immediate / Temporary controls have been put in place to control this Environmental Incident?

  • Select the Plant and Equipment Type

  • Enter Description

  • Injury Type Classification

  • Enter Identification Number if Available

  • Vehicle Info

  • Vehicle
  • Make

  • Model

  • Registration No

  • Identification No.

PART B

Incident Risk

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  • Categorise Risk Likelihood

  • Categorise Risk Consequence

  • Using your responses above, select the overall category from the matrix diagram.

  • Complete the Accident and Incident Investigation Form. Notify HSEQ department and Supervisor /Manager

  • Full investigation to be completed within 5 working days by investigation team. Notify HSEQ Manager and area / contract Manager

  • Full investigation to be completed immediately by investigation team. Notify HSEQ Manager and EGM Immediately.

Contributing Factors

  • Standard Conditions

  • Standard Acts and Practices

  • Details of contributing factors.

  • Root Cause

  • Detail of Root Causes

  • In your opinion was this incident the result of an unsafe act or an unsafe condition?

Part C

Associated Actions

  • Details of actions / recommendations

  • Priority

  • Who is accountable for ensuring these actions are complete?

Part D

  • EGM or Operations Managers comments

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  • Add signature

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